Inspection Reports for
Crestpark Forrest City, LLC
500 Kittle Rd, Forrest City, AR 72335, AR, 72335
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
23 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
342% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
34% occupied
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 48
Deficiencies: 7
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication storage, food service, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure safe environment after resident falls, improper storage of controlled medications, failure to serve meals according to planned menus and at proper temperatures, inadequate preparation of pureed foods, unsanitary conditions in food service areas, and failure to follow enhanced barrier precautions for infection control.
Deficiencies (7)
Failure to ensure a safe and secure environment after resident falls, including lack of notification to provider or hospice and inadequate follow-up.
Failure to ensure refrigerated narcotics were stored in a permanently affixed storage box to prevent misappropriation.
Failure to ensure meals were prepared and served according to the planned written menu to meet nutritional needs.
Failure to serve meals at acceptable temperatures and maintain palatability.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency.
Failure to maintain clean and sanitary conditions of ice machines, proper storage of dairy and food items, and proper hand hygiene by dietary staff.
Failure to follow enhanced barrier precautions when flushing a feeding tube for a resident requiring such precautions.
Report Facts
Residents affected: 2
Residents affected: 6
Residents affected: 24
Residents affected: 2
Residents affected: 46
Census: 48
Feeding tube flush volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #12 | LPN | Named in fall safety and feeding tube flushing findings |
| Licensed Practical Nurse #14 | LPN | Named in fall safety findings |
| Director of Nursing | DON | Interviewed regarding fall incidents and facility policies |
| Licensed Practical Nurse #13 | LPN | Interviewed regarding medication storage deficiency |
| Dietary Manager #11 | Dietary Manager | Interviewed and observed regarding food service and sanitation deficiencies |
| Dietary Aide #3 | Dietary Aide | Observed and interviewed regarding food preparation and hand hygiene deficiencies |
| Dietary Aide #4 | Dietary Aide | Observed food temperatures and interviewed regarding reheating procedures |
| Certified Nursing Assistant #9 | CNA | Interviewed regarding pureed food consistency |
| Administrator | Administrator | Interviewed regarding infection control policies and enhanced barrier precautions |
Inspection Report
Routine
Census: 48
Deficiencies: 7
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication storage, food service, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure safe environment and proper notification after resident falls, improper storage of controlled medications, failure to serve meals according to planned menus and at proper temperatures, inadequate preparation of pureed foods, unsanitary conditions in food service areas, and failure to follow enhanced barrier precautions during feeding tube care.
Deficiencies (7)
Failed to ensure a safe and secure environment by not adhering to policies after resident falls, including failure to notify provider or hospice and failure to send resident for evaluation.
Failed to ensure refrigerated narcotics were stored in a permanently affixed locked container inside the medication room.
Failed to ensure meals were prepared and served according to the planned written menu, resulting in residents receiving less food than planned.
Failed to ensure meals were served at acceptable temperatures and maintained appearance to encourage nutritional intake.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency, posing risk of choking or complications.
Failed to maintain ice machines and food storage areas in clean and sanitary condition, including presence of expired food items and improper hand hygiene by dietary staff.
Failed to follow enhanced barrier precautions when flushing a feeding tube for a resident, including lack of PPE use despite policy expectations.
Report Facts
Residents affected: 2
Residents affected: 6
Residents affected: 5
Residents affected: 24
Residents affected: 12
Residents affected: 8
Total census: 48
Temperature readings: 117
Feeding tube flush volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #12 | LPN | Interviewed regarding fall incident and observed flushing feeding tube without PPE |
| Licensed Practical Nurse #14 | LPN | Interviewed regarding fall incident and notification procedures |
| Director of Nursing | DON | Interviewed regarding fall incidents and notification policies |
| Dietary Manager #11 | Dietary Manager | Interviewed regarding food service deficiencies and ice machine sanitation |
| Dietary Aide #3 | Dietary Aide | Observed and interviewed regarding food preparation and hand hygiene |
| Dietary Aide #4 | Dietary Aide | Observed food temperatures and interviewed regarding reheating procedures |
| Certified Nursing Assistant #9 | CNA | Interviewed regarding consistency of pureed sausage |
| Administrator | Administrator | Interviewed regarding enhanced barrier precautions and facility policies |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding ice machine cleaning frequency |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements and supervision protocols related to residents with wandering and elopement risks.
Findings
The facility failed to ensure that care plans were revised to accurately reflect wandering behaviors and preventive interventions for residents at risk of elopement. Additionally, the facility did not provide adequate supervision to prevent a cognitively impaired resident from exiting the facility unsupervised.
Deficiencies (2)
Failure to revise care plans to accurately indicate wandering behaviors with interventions to prevent elopement for 2 residents.
Failure to provide adequate supervision to prevent a resident with moderate cognitive impairment and exit seeking behaviors from exiting the facility unsupervised.
Report Facts
Resident admission days: 13
Resident wandering frequency: 1
Resident wandering frequency: 3
Distance resident found from exit: 60
Time resident was out of facility: 7
Inspection Report
Deficiencies: 2
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements and supervision protocols related to residents with wandering and elopement risks.
Findings
The facility failed to ensure care plans were revised to accurately reflect wandering behaviors and preventive interventions for residents at risk of elopement. Additionally, the facility failed to provide adequate supervision to prevent a resident with moderate cognitive impairment and exit-seeking behavior from leaving the facility unsupervised.
Deficiencies (2)
Failure to revise care plans to accurately indicate wandering behaviors with interventions to prevent elopement for 2 residents.
Failure to provide adequate supervision to prevent a resident with moderate cognitive impairment and exit-seeking behaviors from exiting the facility unsupervised.
Report Facts
Residents reviewed for wandering behaviors: 3
Residents affected by wandering care plan deficiency: 2
Residents reviewed for elopement: 3
Residents affected by supervision deficiency: 1
Resident #1 BIMS score: 12
Resident #3 BIMS score: 9
Resident #1 time out of facility: 7
Distance resident #1 found from exit: 60
Resident #1 admission length: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided statements regarding facility policies and confirmed resident supervision details. | |
| MDS Coordinator | Confirmed details about Resident #1's care plan and admission length. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 23, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely incontinent care to a resident dependent on staff for such care.
Complaint Details
The complaint was substantiated based on record review, observation, and interviews indicating Resident #1 was left in soiled briefs and sheets for extended periods due to staff prioritizing other residents and isolation precautions.
Findings
The facility failed to ensure incontinent care was provided in a timely manner for one sampled resident. Interviews and observations confirmed delays in care, particularly for a resident on isolation precautions.
Deficiencies (1)
Failure to provide timely incontinent care to Resident #1 who was dependent on staff.
Inspection Report
Deficiencies: 1
Date: Oct 23, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing appropriate treatment and care according to orders, resident preferences, and goals, specifically focusing on incontinent care for sampled residents.
Findings
The facility failed to ensure timely incontinent care for one of three sampled residents who depended on staff for such care. Resident #1 was found to have been left in soiled briefs and sheets for an extended period, with staff interviews revealing delays in care due to isolation precautions and workload.
Deficiencies (1)
Failure to provide timely incontinent care for Resident #1 as required by care plan and physician orders.
Report Facts
Residents sampled: 3
Isolation duration: 10
Inspection Report
Routine
Census: 43
Deficiencies: 2
Date: Aug 18, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, and homelike environment for residents, including proper upkeep, maintenance, and pest control.
Findings
The facility failed to maintain resident rooms in good repair, clean, and free of odors, with issues such as black substance on air conditioner vents, food debris, urine odors, and damaged molding. Additionally, the facility failed to maintain an effective pest control program, with observations of flies, roaches, spiders, crickets, and rodents in multiple areas and resident rooms.
Deficiencies (2)
Resident rooms were not maintained in good repair, clean, and free of odors, including black substance on air conditioning vents, food debris, urine odors, and damaged molding.
Failed to maintain an effective pest control program to prevent and deal with mice, insects, or other pests, with presence of flies, roaches, spiders, crickets, and rodents observed.
Report Facts
Residents affected: 43
Resident rooms with deficiencies: 5
Resident rooms with pest issues: 7
Number of flies observed: 8
Number of crickets observed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Accompanied Surveyor to resident room to show window leak and discussed maintenance reporting process | |
| Administrator | Reported facility did not have policies on facility upkeep, maintenance, and pest control | |
| Dietary Employee #3 | Dietary Employee | Reported pest problems with flies in the kitchen area |
Inspection Report
Routine
Census: 42
Deficiencies: 7
Date: Aug 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, facility maintenance, nutrition services, food safety, and pest control at Crestpark Forrest City nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide residents the opportunity to formulate advance directives, poor maintenance and cleanliness of resident rooms, failure to prepare and serve meals according to prescribed diets and menus, inadequate food safety and sanitation practices, and ineffective pest control program with evidence of pests in resident rooms and facility areas.
Deficiencies (7)
Failed to ensure residents were provided the opportunity to formulate an Advance Directive.
Resident rooms were not maintained in good repair, clean, and free of odors; presence of black substance on air conditioning vents, urine odor, peeling molding, holes in walls.
Meals were not prepared and served according to the planned written menu and physician orders, including incorrect food items and portion sizes.
Hot foods were not served hot and cold foods not served cold, compromising palatability and nutritional intake.
Pureed food items were not blended to a smooth, lump-free consistency, risking choking.
Food storage and handling practices were inadequate, including uncovered and unsealed food items, expired products, contaminated gloves, and dirty ice machines.
Pest control program was ineffective; presence of flies, roaches, spiders, crickets, and rodents observed in multiple resident rooms and facility areas.
Report Facts
Residents affected: 42
Resident rooms with maintenance issues: 5
Meals observed: 2
Ice machines inspected: 2
Resident rooms and facility areas with pest issues: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Reported no policy on facility upkeep and maintenance and no policy on pest control | |
| Director of Nursing (DON) | Provided facility policies, described procedures for advance directives and dietary orders | |
| Dietary Supervisor | Provided lists of residents with dietary needs, described food safety and pest control issues | |
| Dietary Employees (DE #1, DE #3, DE #4, DE #5) | Observed serving incorrect food portions, handling food with contaminated gloves, and unaware of resident dietary preferences | |
| Certified Nursing Assistants (CNA #1, CNA #2) | Described consistency of pureed foods served to residents | |
| Maintenance Supervisor | Reported on facility maintenance procedures and knowledge of repairs | |
| Dietary Supervisor in Training | Described food safety and dietary order processes |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 18, 2023
Visit Reason
The inspection was conducted as a regulatory survey to assess compliance with health and safety standards, focusing on the facility's environment, pest control program, and maintenance.
Findings
The facility was found to have multiple deficiencies including poor maintenance of resident rooms with black substances on air conditioning units, food debris, and damaged walls; ineffective pest control with presence of flies, roaches, spiders, and rodents; and lack of policies on facility upkeep and pest control.
Deficiencies (3)
Resident rooms were not maintained in good repair, clean, and free of odors, with black substance on air conditioning vents, food debris, wet urine-smelling fall mats, and damaged molding and walls.
Facility failed to maintain an effective pest control program, with presence of flies, roaches, spiders, crickets, and rodents in multiple resident rooms, kitchen service areas, and halls.
Facility lacked policies on upkeep, maintenance, and pest control.
Report Facts
Residents affected: 5
Residents affected: 43
Number of rooms with pest issues: 7
Number of flies observed: 8
Number of crickets observed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Accompanied Surveyor to resident room and discussed maintenance issues | |
| Administrator | Reported lack of policies on facility upkeep and pest control | |
| Dietary Employee #3 | Reported problems with flies in the kitchen area |
Inspection Report
Routine
Census: 42
Deficiencies: 7
Date: Aug 18, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident rights, facility environment, nutrition, food safety, and pest control.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, poor maintenance and cleanliness of resident rooms, failure to prepare and serve meals according to prescribed diets and menus, inadequate food safety and sanitation practices in the kitchen, and ineffective pest control program with evidence of pests in resident rooms and facility areas.
Deficiencies (7)
Failed to ensure residents or responsible parties were provided the opportunity to formulate an Advance Directive and maintain written policies regarding advance directives.
Failed to maintain resident rooms in good repair, clean, and free of odors, including presence of black substance on air conditioning vents, urine odor, and holes in walls.
Failed to ensure meals were prepared and served according to the planned written menu and physician orders, including serving incorrect food items and improper portion sizes.
Failed to serve hot foods hot and cold foods cold to maintain palatability and encourage adequate nutritional intake.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to ensure foods stored in dry storage, refrigerator, and freezer were covered, sealed, dated, and free from expired items; failed to maintain clean ice machines and proper hand hygiene among dietary staff.
Failed to maintain an effective pest control program, with observations of flies, roaches, spiders, crickets, and evidence of rodents in resident rooms and facility areas.
Report Facts
Residents affected: 42
Resident rooms observed with deficiencies: 5
Meals observed: 2
Ice machines inspected: 2
Pest control service invoices reviewed: 17
Inspection Report
Routine
Census: 42
Deficiencies: 15
Date: Jun 3, 2022
Visit Reason
Routine inspection of Crestpark Forrest City, LLC nursing home to assess compliance with regulatory requirements including resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to notify Medicaid residents of trust fund balances, inadequate posting of survey results, incomplete advance directive documentation, failure to inform residents timely about Medicare coverage changes, unsanitary bathroom conditions, malfunctioning air conditioning, inaccurate resident assessments, missing PASARR screenings, incomplete care plans, delayed call light responses, lack of assistive devices for contractures, unsecured bed rails, improper PEG tube care, failure to serve menu items as planned, improper food storage and handling, and inadequate infection control practices.
Deficiencies (15)
Failed to notify Medicaid recipient residents when their trust balance was within or approaching $200 of the maximum Medicaid recipient cash assets.
Failed to ensure the most recent federal survey results were readily accessible to residents and representatives.
Failed to ensure residents were provided information on their right to formulate an advance directive and document decisions.
Failed to inform residents timely of changes in Medicare Part A services and reimbursement.
Failed to maintain a safe, clean, comfortable, and homelike environment including functioning air conditioning and clean bathrooms.
Failed to ensure Minimum Data Set assessments accurately reflected resident conditions such as smokeless tobacco use.
Failed to complete PASARR screenings for residents with mental disorders or intellectual disabilities.
Failed to create care plans addressing residents' diagnoses such as Bipolar Disorder.
Failed to respond timely to call lights for residents dependent on staff for repositioning.
Failed to provide assistive devices such as hand rolls to prevent contractures.
Failed to ensure bed rails were secure and in good working condition to prevent injury.
Failed to follow physician orders for cleaning PEG tube site to prevent infection.
Failed to serve meals in accordance with the planned menu; bread was not served due to expiration.
Failed to ensure proper food storage, discard expired food, maintain cleanliness, and practice proper hand hygiene and glove use during food preparation.
Failed to implement infection prevention and control program including proper mask use and laundry handling to prevent cross-contamination.
Report Facts
Residents affected: 5
Residents affected: 42
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 40
Residents affected: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding trust fund notification, survey results accessibility, Medicare coverage notification, air conditioning repair, PASARR screenings, care plans, and infection control | |
| Director of Nursing (DON) | Interviewed regarding advance directives, PASARR screenings, care plans, hand roll use, and bed rail condition | |
| Licensed Practical Nurse (LPN) #1 | Provided information on resident care, PEG tube cleaning, and resident tobacco use | |
| Certified Nursing Assistant (CNA) #5 | Observed turning off call light and assisting resident | |
| Certified Nursing Assistant (CNA) #6 | Interviewed about call light response | |
| Certified Nursing Assistant (CNA) #8 | Interviewed about call light response | |
| Maintenance Supervisor | Interviewed about bed rail condition | |
| Assistant Dietary Manager | Interviewed about meal preparation and food storage | |
| Laundry Employee #3 | Observed folding clothes and interviewed about laundry procedures | |
| Laundry Employee #2 | Interviewed about dryer maintenance | |
| Dietary Employee #1 | Observed food preparation and improper hair covering | |
| Dietary Employee #2 | Observed improper glove use during food service | |
| Dietary Employee #3 | Observed improper glove use during food service | |
| Housekeeping Staff #1 | Observed improper mask use | |
| Certified Nursing Assistant (CNA) #1 | Observed improper mask use | |
| Certified Nursing Assistant (CNA) #2 | Observed improper mask use |
Inspection Report
Routine
Census: 42
Deficiencies: 15
Date: Jun 3, 2022
Visit Reason
Routine inspection of Crestpark Forrest City, LLC nursing home to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility had multiple deficiencies including failure to notify residents about Medicaid trust balances, inadequate posting of survey results, incomplete advance directive documentation, failure to inform residents timely about Medicare coverage changes, unsanitary bathroom conditions and non-functioning air conditioning, inaccurate resident assessments, missing PASARR screenings and care plans, delayed call light response, lack of hand roll use, loose bed rails, unclean laundry area, improper PEG tube care, failure to serve menu items as planned, improper food storage and handling, and inadequate infection control practices.
Deficiencies (15)
Failed to notify Medicaid recipient residents when trust balances approached maximum allowable limits.
Failed to ensure most recent federal survey results were accessible to residents and families.
Failed to provide and document residents' rights regarding advance directives.
Failed to timely inform residents of changes in Medicare Part A services and reimbursement.
Bathroom in resident room smelled of urine and was unclean; air conditioning not functioning properly.
Minimum Data Set assessments did not accurately reflect resident tobacco use.
Failed to complete PASARR screening for residents with qualifying diagnoses.
Failed to develop care plan addressing bipolar disorder diagnosis for a resident.
Call light for resident was not answered timely, delaying assistance for repositioning.
Resident with contractures did not have hand rolls in place as required.
Loose bed rails on resident's bed posed safety risk; laundry area behind dryers was dusty and cluttered.
Failed to follow physician orders for cleaning PEG tube site, risking infection.
Meals were not prepared and served according to the planned menu; bread was not served due to expiration.
Food storage and handling practices were inadequate, including expired products, unsealed packaging, food on floor, and improper glove use during food preparation.
Infection control practices were inadequate; staff failed to wear masks properly and handled laundry improperly risking cross-contamination.
Report Facts
Residents affected: 5
Residents affected: 42
Residents affected: 1
Residents affected: 1
Residents affected: 42
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 40
Residents affected: 40
Residents affected: 42
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